Provider Demographics
NPI:1750318580
Name:DIEDERICH, SUSAN N (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:N
Last Name:DIEDERICH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:N
Other - Last Name:BRAHM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:16800 WEST CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-3533
Mailing Address - Country:US
Mailing Address - Phone:262-432-2005
Mailing Address - Fax:
Practice Address - Street 1:1260 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-9315
Practice Address - Country:US
Practice Address - Phone:262-546-0234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2981-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38624700Medicaid
WI2981OtherEYEMED VISION NO.
WI2981OtherEYEMED VISION NO.
WIV01392Medicare UPIN